The home health aide caring for a home bound hospice client calls to inform the nurse that the client has reported feeling constipated. Which task should the nurse instruct the home health aide to perform?
Listen for the presence of bowel sounds.
Teach the client about foods high in fiber.
Administer a prescribed dose of a laxative.
Assist the client in drinking warm prune juice.
The Correct Answer is D
Choice A Reason: Listening for the presence of bowel sounds is not a task that the home health aide can perform, as it requires a stethoscope and clinical judgment. This task is within the scope of practice of the nurse, who should assess the client's bowel function and abdominal status.
Choice B Reason: Teaching the client about foods high in fiber is not a task that the home health aide can perform, as it requires knowledge and education skills. This task is within the scope of practice of the nurse, who should provide dietary advice and counseling to the client and their family.
Choice C Reason: Administering a prescribed dose of a laxative is not a task that the home health aide can perform, as it requires medication administration skills and authority. This task is within the scope of practice of the nurse, who should check the medication order, verify the dosage and route, and document the administration.
Choice D Reason: Assisting the client to drink warm prune juice is a task that the home health aide can perform, as it requires basic care and assistance skills. This task is appropriate for the home health aide, who should encourage fluid intake and offer natural remedies for constipation, such as prune juice, which has laxative effects.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason: Instructing UAPs to transfer all non-ambulatory clients via wheelchairs is not a good intervention, as it may expose the clients and the UAPs to smoke and fire, and cause panic and congestion in the hallways. The charge nurse should follow the RACE protocol (Rescue, Alarm, Contain, Extinguish), which means rescuing only those clients who are in immediate danger, and containing the fire by closing doors and windows.
Choice B Reason:Following the RACE acronym, evacuation of those in immediate danger is the priority. Instructing ambulatory clients to move toward the nearest fire exit is the most efficient way to clear the unit. Nursing staff must guide these individuals to safety first to minimize congestion and allow for focused assistance.
department's efforts. The charge nurse should follow the RACE protocol, which means evacuating only as a last resort, and only after receiving instructions from the fire department.
Choice C Reason: Staying in rooms is a "defend in place" strategy, but it is inappropriate once an official evacuation order has been issued by the operator. Closing doors is vital to contain smoke and fire, but instructing everyone to remain stationary during an active evacuation order increases the risk of injury.
Choice D Reason: Announcing in a calm voice that all visitors should proceed immediately to the first floor via the service elevators is not a good intervention, as it may endanger the visitors and cause more damage. The charge nurse should follow the RACE protocol, which means alarming others by activating the fire alarm system and calling 911. The charge nurse should also instruct visitors not to use elevators during a fire, as they may malfunction or trap them inside.
Correct Answer is B
Explanation
Choice A Reason: Waiting until the end of the second week to see if the orientee is able to complete her assignments is not the best action for the charge nurse to take. This would delay providing feedback and support to the orientee, who may feel frustrated and discouraged by her performance. The charge nurse should intervene as soon as possible to help the orientee improve her skills and confidence.
Choice B Reason: Assigning the orientee to work with an experienced nurse who is a long-time, efficient employee is the best action for the charge nurse to take. This would provide the orientee with a role model and a mentor who can guide her through the daily tasks, share tips and tricks, and offer constructive feedback and encouragement. The orientee would benefit from learning from someone who has mastered the workflow and expectations of the unit.
Choice C Reason: Informing the supervisor that for client safety this nurse should be assigned to a slower-paced unit is not the best action for the charge nurse to take. This would imply that the orientee is incompetent and unsuitable for the unit, which may damage her self-esteem and motivation. The charge nurse should first try to help the orientee adjust to the unit and develop her competencies before considering a transfer.
Choice D Reason: Talking to the orientee and asking her if she has considered working in a less stressful environment is not the best action for the charge nurse to take. This would suggest that the charge nurse has given up on the orientee and does not believe in her potential. The charge nurse should first try to understand the challenges and needs of the orientee and provide appropriate guidance and support before suggesting alternative career options.
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